1. Field of the Invention
The present invention relates to a method and interactive system which establis a protocol of appointments, examinations, diagnostics, procedures and therapy in the treatment of Temporomandibular Disorders (TMD) by a dentist, from which properly coded medical insurance claim forms are generated, increasing the probability of approval of payments to the dentist.
2. Description of the Related Art
Two common health benefits employers provide to employees are medical insurance plans and dental insurance plans. Both medical insurance and dental insurance plans can vary in the types of coverages that are offered. The term “insurance plan” extends to any contractual or other legal arrangement whereby medical and other related expenses are paid on behalf of a beneficiary. Examples of insurance plans include health maintenance organizations, preferred provider organizations, fee-for-service health care plans, employer-sponsored insurance plans, etc. Most insurance plans cover illness and injuries at certain percentage levels and may include co-payments, deductibles and coverage limits. A typical medical insurance plan might be one where the insurer will pay 80% of physician's bill associated with the diagnosis and treatment of a condition. The patient would be expected to pay the remaining 20% of the bill, after paying a deductible (a predetermined minimum contractual amount that must be paid before the insurance plan begins coverage) and co-payment (a per visit amount paid before coverage is extended).
Dental insurance plans can be similar to medical insurance plans, but typically coverages are at lower levels and have higher co-payments and deductible amounts than medical insurance plans. A typical dental insurance plan might cover preventive and diagnostic services at 100% (generally cleanings and checkups), but will cover more involved treatments at lower percentages. For example, basic services might be covered at 80%, major services and orthodontics might be covered at only 50%. In addition, dental insurance plans often have both annual and lifetime maximum benefits, for example, an annual per person maximum of $1,200 or a lifetime per person of $1,500 for orthodontics are routinely used limitations. Further, deductibles and co-payments may apply, further limiting benefit coverage.
Typically, medical doctors diagnose and treat medical conditions, and look to medical insurance plans for reimbursement. Dentists diagnose and treat dental conditions, and seek reimbursement from dental insurance plans.
In situations where a Dentist provides treatment to a patient where, under medical and dental industry standards, medical insurance coverage could be utilized instead of dental insurance coverage, several advantages could be realized. Because medical insurance coverage percentages and limits are generally higher, a Dentist able to process an insurance claim under a medical insurance plan rather than dental insurance plan could recover greater amounts from the insurer and less from the patient, reducing the need for arranging patient payment of uninsured costs and payment collections, as well as higher patient satisfaction in obtaining services for lower out-of-pocket cost to the patient.
Medical claim forms are filled out and submitted to insurance companies containing industry standard numerical descriptions known as ICD 9 (International Statistical Classification of Diseases and Related Health Problems codes) codes and CPT (Current Procedural Terminology) codes. An ICD 9 code describes a specific medical condition or diagnosis. CPT codes describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. An additional 2 digit modifier may be added to a CPT code following a decimal point to clarify or modify a procedure.
The purpose of the coding system is to provide uniform and standardized descriptions that accurately describes medical conditions and the medical, surgical, and diagnostic services used to treat these conditions. The rules for assigning ICD 9 and CPT codes are complicated and extremely detailed. Training and experience is necessary to consistently and properly apply the appropriate codes in a manner to insure medical health claims are processed correctly and paid promptly.
A submitted medical insurance claim form typically contains ICD-9 code or codes, describing a condition. For each ICD code listed in an insurance claim form, a health care provider may decide to implement a treatment or treatments, each of which has a CPT Code that describes it. Together, the ICD code is matched with the appropriate CPT code or codes detailing the diagnosis and treatment of a condition. The codes used are examined, both manually and by the use of computer software to insure that the procedure and the diagnosis are related and that the procedure is one of medical necessity for that diagnosis.
A large portion of the medical expenses incurred by patients in this country are paid by private or government based insurance plans. Agencies such as health insurers, health care consultants, government offices (i.e. Medicare/Medicaid) routinely examine health claim forms to verify that the treatments being administered fall within accepted guidelines to avoid paying for unnecessary or unconventional treatments, as well as to prevent overpayments due to improper coding. Also, because of the high rates of insurance fraud, these agencies rely on computer and manual audits to analyze submitted documentation and deny claims when these audits detect irregularities. This necessitates that forms be coded properly the first time to avoid the red tape and bureaucracy that is involved to correct mistakes that result in denial of claims. By automating the process, human error is minimized and coding is done correctly according to industry standards, thereby reducing the rates of claim rejection.
The temporomandibular joint connects the lower jaw (mandible), to the temporal bone at the side of the head. Because these joints are flexible, the jaw can move smoothly up and down and side to side, enabling actions such as speech, chewing and yawning. Muscles attached to and surrounding the jaw joint control its position and movement.
Temporomandibular Disorder (TMD) describes a group of conditions that affect the Temporomandibular Joint (TMJ) and the related muscles. TMD generally refers to the more general diagnosis of one of the following specific conditions:
TMJD (Temporo-Mandibular Joint Dysfunction)
TMJ (Temporo-Mandibular Joint)
TMD (Temporo-Mandibular Disorder)
CFD (Cranio-Facial Disorder)
CCD (Cranio-Cervical Disorder)
CMD (Cranio-Mandibular Disorders)
These various disorders usually involve similar symptoms, which include pain, dysfunction and impairment involving the head, neck, ears and jaws. TMD diagnosis and treatment fall into 2 general categories:
Extra-capsular—any condition outside the TMJ capsule
Intra-capsular—involving in the working inside the TMJ capsule.
Extra-capsular TMDs are considered soft tissue injuries and are typically covered by dental insurance, whereas intra-capsular conditions are considered hard tissue problems involving trauma-related injuries, and may be covered by the patients' medical insurance since they are considered to be medical rather than dental treatments.
Because treatment may involve either category of insurance, it is important that not only the proper coding be used but that the coding be classified under the proper type of insurance. Because medical and dental insurance coverages are fundamentally different, proper claim submission for Intra-capsular Temporomandibular Disorders would involve experience and knowledge in two very different areas of insurance claim coding.
Because intra-capsular injuries are non-surgical problems, claims may be submitted under a patient's medical insurance coverage. A dentist treating these conditions must have the ability to effectively code both diagnosis and treatment under the proper ICD 9 and CPT medical codes to insure medical insurance claims will be paid promptly and not rejected.